CASE XII.-A lady, aged 49, had been in bad health through the winter 1811-12, complaining chiefly of weakness and a constant uneasiness across the region of the stomach, with occasional attacks of acute pain towards the left side. In May 1812, she began to have vomiting, which continued from that time, and became more and more urgent. I saw her in July, and found her much emaciated; she complained of a dull pain in the epigastric region, where considerable hardness was felt; and she vomited a portion of every thing she took, sometimes immediately after taking it, and sometimes a considerable time after. She continued with little change till the beginning of September, when the vomiting subsided, and she was free from it for more than a fortnight. But during this time she was affected with diarrhoea; her strength sunk, and she died on the 23d,-the vomiting having returned, though with less severity, three or four days before death. During the period when she was free from vomiting, she took food and drink of various kinds, and in very considerable quantity, and continued to do so till a few hours before death.

Inspection.-On opening the abdomen and looking for the stomach, a large irregular opening presented itself, which was found to lead into the cavity of the stomach, in consequence of a large extent of its great arch being entirely destroyed. In the left side, there was a large irregular mass, which appeared to consist of an enlarged and diseased spleen and the remains of the great arch of the stomach, so blended into one mass, that it was impossible to distinguish one part from another; in the substance of it there was a cyst full of very fetid matter. This mass was attached to the cardia by a narrow portion, which remained of the coats of the stomach at that place; and when the parts were taken out and displayed, by suspend

ances were very remarkable. manner, about one-half of the

ing the stomach by the cardia and the pylorus, the appearWhen stretched out in this stomach at the pyloric extremity was sound and healthy. This part was attached to the cardia by a narrow portion of the small curvature which remained; and by another small portion of the greater curvature, the large irregular mass now referred to hung down on the left side. The left side and the lower part of the great arch of the stomach were entirely wanting to such an extent, that, when the parts were extended in the manner now mentioned, it seemed as if nearly one half of the stomach had been entirely destroyed. There was reason to believe that the part which seemed to be wanting was involved in the diseased mass on the left side. The sound parts were separated from this portion by a line of ulceration of such extent, that the pyloric extremity remained attached to the cardia only by a portion about two inches in breadth which remained of the small arch. The ulcerated edge, where the separation had taken place, was studded with numerous hard tubercles like the edges of a cancerous ulcer. The pancreas was hard; the liver was pale and soft; the other viscera were healthy.

Various instances are on record of the true melanosis of the stomach, but I have not thought it necessary to detail examples of it, as they do not present phenomena remarkably different from the affections which have been described. The affected portion of the stomach is generally much thickened, and, on its internal surface, ulcerated. In its structure it presents various degrees of consistency, but the whole is more or less deeply tinged with that peculiar black matter from which it has derived its name. The symptoms do not differ from those of the other cases. of organic disease of the stomach with ulceration, except

that the matters vomited are often deeply tinged with the dark melanotic discharge from the ulcerated surface.

DIAGNOSIS AND TREATMENT OF THE AFFECTIONS OF THE STOMACH REFERRED TO UNDER THE PRECEDING HEADS.

From the facts which have been related, we have every reason to conclude, that the dangerous affection referred to in the preceding observations exists in two conditions ; namely, chronic inflammation of a defined portion of the mucous membrane of the stomach, or the mucous follicles,and the termination of this by ulceration. In both these conditions, it may probably be the subject of medical treatment; for we have reason to believe, that the inflammation may be arrested and prevented from passing into ulceration, and that the ulceration may heal before it has become connected with any permanent change in the organization of the part. Hence appears the importance of minutely watching the progress of the disease in its early stages, in which only it is likely to be treated with success. The difficulty here is in the diagnosis,-the disease often assuming the character of a mere dyspeptic affection through a great part of its progress; while, in fact, a morbid condition of a very serious nature is going on, which would require treatment in many respects very different from that adapted to dyspepsia.

The disease may be suspected, when there is pain in the stomach occurring with considerable regularity immediately after meals, and continuing for a certain time during the process of digestion,-especially if the pain be distinctly

referred to a particular spot, and if there be at that spot tenderness on pressure. It may be farther suspected, if the pain continues severe until the patient is relieved by vomiting; but we have seen that the disease may go on to a very advanced period without vomiting, and, on the other hand, that it is sometimes indicated by vomiting occurring occasionally, without any regular periods, and with very little pain. In the cases will be seen other important varieties in the symptoms, which are of great interest in a practical point of view, particularly the intense and peculiar feeling of pyrosis mentioned in Case VIII. When this feeling occurs with great intensity after food of all sorts, taken even in the most moderate quantities, we have reason to suspect disease of the mucous membrane of the stomach. The feeling appears to be in some cases connected with the formation of an acrid fluid, which we often see brought up in considerable quantities; and in others, seems to depend merely upon the morbid condition of the mucous membrane itself, in consequence of which, ordinary articles produce that peculiar feeling of irritation, which in the sound state of the parts is produced by matters of an acrid quality. It is common to hear such patients say, that attention to diet makes little difference in their feelings, but that every thing turns immediately to intense acidity, even a bit of meat or a glass of cold water. The disease may be also suspected, when, along with any of the above mentioned symptoms, though in a mild and obscure form, the patient is becoming weakened and emaciated in a manner which a mere dyspeptic affection could not account for. The affection, again, is sometimes accompanied and characterized by a raw and tender state of the tongue and throat; in some cases, with minute ulcers; and in others, with the formation of slight aphthous crusts. One gentleman lately stated to me that his complaint be

gan with minute ulcers and a burning sensation on the tongue, and that he afterwards distinctly felt the same state of disease extending gradually along the oesophagus, and at last into the stomach.

Amid such a diversity of symptoms as occur in connection with this disease, our chief reliance in the diagnosis must probably be on a careful examination of the region of the stomach itself, with the view of discovering the existence of tenderness referred to a particular part. This examination should be made with the most minute attention, at various times, both when the stomach is full and when it is empty. If induration be discovered, the character of the case will be obvious; but we have seen, that most extensive ulceration may exist without any induration; and likewise, that extensive induration may exist without being discovered by external examination.

In

Other important cautions in regard to the diagnosis will be learned from the cases which have been described. particular, we should not be deceived, either by the pain having remarkable remissions and the patient enjoying long intervals of perfect health, or by remarkable alleviation of the symptoms taking place under a careful regulation of diet; for these circumstances we have found occurring in a very striking manner, while the disease was making progress to its fatal termination.

When the disease is detected at an early period, the treatment must consist chiefly of free and repeated topical bleeding, followed by blistering, issues, or the tartar emetic ointment. The food must be in very small quantity, and of the mildest quality, consisting chiefly or entirely of farinaceous articles and milk, with total abstinence from all stimulating liquors; and it would appear to be of much consequence to guard against any degree of distention of the

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